Written asthma action plans for adults

Overview

All patients should have an individualised written asthma action plan that outlines:

• the usual preventer and reliever drug regimen
• how to recognise symptoms of asthma deterioration
• when to start or change reliever and preventer therapy, and when to start oral corticosteroid therapy
• when to seek medical attention.

Review the action plan at least annually and whenever therapy is changed.

Asthma action plan templates that can be individualised are available from the National Asthma Council.

Symptom-based action plans are suitable for the majority of patients. Action plans based on peak expiratory flow (PEF) measurements are recommended for patients who are poor perceivers or overperceivers of symptoms, and patients prone to sudden severe exacerbations. Plans based on PEF measurements should use personal-best PEF rather than predicted PEF for action points. A PEF monitoring chart is available from the National Asthma Council.

Principles of adjusting drug therapy for an asthma action plan

For the principles of asthma action plans for adolescents, see Written asthma action plans for children.

Asthma action plans detail steps for adjusting drug therapy that should be followed when symptoms occur. Individualise the plan to the patient’s current treatment regimen, their usual asthma symptoms and pattern of reliever use, and their willingness and ability to self-manage worsening asthma. Also consider the patient’s history of exacerbations, including the severity and their ability to seek appropriate medical attention. Asthma action plan templates that can be individualised are available from the National Asthma Council.

For a mild, transient increase in symptoms, the action plan should recommend that the patient use their reliever therapy. If the symptoms respond well and do not recur, this step is enough.

For a nonurgent but persistent increase in symptoms (eg requiring reliever more than three times per week, symptoms recurring within a few hours of reliever therapy, asthma interfering with daily activities), the action plan should recommend a short-term increase in corticosteroid intake (in addition to using reliever therapy), which can prevent progression to an acute exacerbation. This can be achieved by increasing the dose of inhaled corticosteroids (ICS), or using a short course of oral prednisolone (or prednisone).

Increasing the ICS dose is usually preferred as the initial step because it exposes the patient to a lower total dose of corticosteroid than using oral prednisolone (or prednisone). However, oral prednisolone (or prednisone) may be preferred in patients with a history of severe exacerbations or rapid progression to a severe exacerbation, or patients who cannot tolerate the increased risk of dysphonia with higher ICS doses (eg singers, actors, teachers).

For patients using low- to medium-dose ICS monotherapy, quadrupling the dose of ICS for 1 to 2 weeks is recommended; doubling the ICS dose is not sufficient. If symptoms do not respond to the increased ICS dose, the action plan should recommend that the patient start oral prednisolone (or prednisone) and return to their usual ICS dose.

For patients using low- to medium-dose ICS+LABA combination therapy, oral prednisolone (or prednisone) may be preferred because increasing the ICS dose requires a separate ICS-only inhaler (to avoid excessive LABA dosing), which may not be practical.

For patients using high-dose ICS (either as monotherapy or ICS+LABA combination therapy), increasing the ICS dose further is unlikely to be of additional benefit, so the action plan should recommend oral prednisolone (or prednisone).

For patients using budesonide+formoterol as required, or as maintenance and reliever therapy, taking extra doses on an as-required basis to manage symptoms inherently increases ICS intake. Oral prednisolone (or prednisone) should be added if symptoms do not respond to the extra doses.

Consider the practicality of dose adjustments with the inhaled formulation prescribed. See Inhaled corticosteroid–based inhalers available in Australia for asthma in adults and adolescents  for formulation details of inhalers, including maximum doses of ICS monotherapy and ICS+LABA combination therapy inhalers. Ensure the action plan clearly states the daily maximum number of inhalations specific to the patient’s inhaler.

If a short course of oral prednisolone (or prednisone) is required, use: